Telehealth utilization and patient satisfaction in an ambulatory movement disorders center during the COVID-19 pandemic

Abstract

Introduction

Studies suggest that patients are satisfied with telehealth in ambulatory settings. However, tele-neurology satisfaction data are limited by a small sample size and COVID-19-era data is not specific to movement disorders clinics. In this prospective observational study, telehealth utilization during the COVID-19 pandemic was assessed, and patient satisfaction was compared between telehealth and in-person visits in an outpatient movement disorders center.

Methods

Patients ≥18 years who completed an appointment at Northwestern's Movement Disorders Clinic were invited to complete a post-visit Medallia survey. The primary outcomes of the survey were likelihood to recommend (LTR) provider, LTR location, and ‘spent enough time,’ on a 0–10 scale. Responses were categorized into in-person vs. telehealth groups.

Results

Telehealth utilization significantly increased from a pre-COVID timeframe rate of 0.3% (Nov 2019 to Feb 2020) to 39.5% during the COVID-19 pandemic (March 2020 through April 2021) (p-value < 0.001). During the COVID-19 pandemic, 621 patients responded to the post-visit Medallia survey (response rate = 30%), including 365 in-person and 256 telehealth visits. No significant differences were observed between in-person and telehealth encounters in LTR provider (p = 0.892), LTR location (p = 0.659), and time spent (p = 0.395). Additional subgroup multivariable analysis did not support differences in satisfaction between different age groups.

Discussion

With its large sample size, our study demonstrates that in the setting of increased TH utilization in movement disorders clinic during the COVID-19 pandemic, patients reported similar satisfaction with telehealth compared to in-person visits. This study supports the utility of telehealth to provide specialized neurologic clinic care.

Keywords

Telemedicine patient satisfaction ambulatory clinic movement disorders COVID-19 pandemic telehealth

Introduction

Telehealth (TH) is the practice of using audiovisual communication technology to provide healthcare remotely Telehealth (TH) has been recognized as a useful process of delivering care to people during the coronavirus disease 2019 (COVID-19) pandemic.¹ The rise of the pandemic in the Spring of 2020 catalyzed a dramatic increase in TH utilization, including amongst neurologic sub-specialties.^2,3 For the neurologic sub-specialty of movement disorders in particular, which includes care of Parkinson's disease (PD) patients and others with limited mobility and/or cognitive impairment, TH offered increased patient access to specialized care, overcoming barriers of location, distance, and accessibility of specialized centers.^3–5

Prior to the COVID-19 pandemic, within the movement disorders clinical arena, TH had been slowly adopted and investigated through pilot studies, with the intended advantage of overcoming the patient and care partner burden of accessing a movement disorders clinic with mobility, and potentially, cognitive limitations.⁶ As early as 2006, an observational study of 100 TH visits for 34 PD patients identified savings of approximately 1500 travel hours, 100,000 km and $37,000 in travel and lodging.⁷ The promise of TH to reduce care-related burdens for PD patients spurred investigation into its feasibility for assessing PD motor symptoms. Since 2010, it was proven by multiple studies that remote completion of The Unified Parkinson's Disease Rating Scale (UPDRS) motor component is reliable, and a modified version omitting rigidity and postural instability is also cross-sectionally and longitudinally reliable.^8–10 Knowledge of the reliability of TH to assess PD beget the question of whether it was feasible for patients. Two initial randomized trials of TH versus in-person visits addressed this question by showing high televisit completion rates of 97% (29 of 30) and 93% (25 of 27).^8,11 A larger trial of 195 PD participants demonstrated completion of 91% of 388 virtual visits that were not less efficacious than usual in-person care.¹²

With the goal of delivering patient-centered PD care, demonstration of TH reliability and feasibility is not sufficient; patient satisfaction with virtually-delivered care must be demonstrated. A study of TH visits for 86 men with PD found similar overall satisfaction scores between TH and in-person visits, and greater satisfaction scores for TH regarding accessibility and convenience.¹³ High satisfaction was echoed in an observational study of televisits with median satisfaction-related survey responses of 9.25 on a 10-point Likert scale, with all participants attesting that TH services were valuable, however, this was limited by the small sample size of 13.¹⁴ In the aforementioned larger trial of virtual house calls for 195 PD patients, 97% were satisfied or very satisfied with virtual visits, and participants preferred virtual visits over in-person visits.¹² The largest pre-COVID pandemic evaluation of TH satisfaction in PD included 204 participants enrolled in a clinical trial utilizing TH visits, with virtual visits associated with higher patient satisfaction convenience scores.¹⁵ A survey study of 78 PD patients not only showed patient acceptance of a telemedicine-based care model but also that patients rated their condition better at the end of the program.¹⁶

With the advent of the COVID-19 pandemic accelerating the adoption of TH in clinical practice came the opportunity to analyze patient satisfaction with TH on a larger scale, across the medical field, and in the movement disorders patient population specifically.¹⁷ Our large-scale study of TH utilization and patient satisfaction in a specialized movement disorders clinic contributes significantly to the knowledge of TH's role in clinical care of this specific neurologic population, specifically regarding patient satisfaction, as data to date has been limited by small sample size.

Methods

Northwestern Medicine's Engagement Team created a Medallia electronic survey to assess patient experience and satisfaction amongst the Northwestern Medicine outpatient population. The survey was launched for the Neurology Department in November 2019, and telehealth-specific questions were added in May 2020. Following a patient's in-person or virtual clinic visit, a link to the electronic survey was sent to the patient via email, text message, or Northwestern Medicine MyChart (secure patient portal) message, depending on pre-specified patient preferences. Virtual clinic visits included those conducted by video and telephone. The average survey response rate was 30% with an average time to completion of 5 min.

Statistical analysis

Data are presented as median with interquartile range (IQR) for continuous variables and as proportions with percentages for categorical variables. Comparison between groups was done using chi-square and Fisher's exact tests for categorical variables, and Mann–Whitney U test for parametric and nonparametric variables, respectively. A P value of <0.05 (two-tailed) was considered statistically significant. Statistical analysis was done using R version 4.1.2.

Results

TH utilization at Northwestern Memorial Hospital's movement disorders clinic had a steep rise in the proportion of TH encounters during the transition from March to April 2020, from under 25% to over 90% of encounters (Figure 1). TH utilization gradually trended downward toward a baseline of 24% of visits until November 2020 through January 2021 when the rates rose again, correlating with a “second wave” of Covid-19 cases in the United States.

Figure 1.

Proportion of telehealth and in-person clinic visits from March 2020 to April 2021 at Northwestern's movement disorders clinic.

Comparing TH rates pre-Covid (Nov 2019–Feb 2020) to post-COVID (Mar 2020–April 2021) timeframes, rates increased from 0.3% to 39.5% (Table 1). The majority of pre-COVID encounters were in-person (89%) and return visits (78%). There was a significant difference in visit types when comparing pre-COVID encounters to during COVID encounters; specifically, a higher proportion of clinical encounters were new patient encounters in the pre-COVID timeframe (pre-COVID: 22%, during-COVID: 16%, p-value = 0.001) (Table 1). Regarding patient satisfaction parameters, survey data examining the likelihood-to-recommend (LTR) scores showed no difference between the pre-COVID and during-COVID clinical encounters, both in patients’ LTR the location and provider.

Table 1.

Demographic and patient satisfaction comparison between pre-COVID and during-COVID in-person and telehealth visits.

	Pre-COVID (N = 312)	During COVID (N = 648)	p value
Age (years)			0.566
Number with data	312	648
Median (IQR)	68.0 (59.8, 74.0)	69.0 (59.0, 74.0)
Range	20.0–95.0	17.0–93.0
Gender			0.605
Number with data	312	648
Female	150 (48.1%)	300 (46.3%)
Male	162 (51.9%)	348 (53.7%)
Visit Type			<0.001
Number with data	312	648
In-person	277 (88.8%)	365 (56.3%)
Telehealth/video	1 (0.3%)	256 (39.5%)
study	34 (10.9%)	27 (4.2%)
New or return visit			0.030
Number with data	312	648
Return visit	244 (78.2%)	544 (84.0%)
New visit	68 (21.8%)	104 (16.0%)
Likelihood to recommend location			0.517
Number with data	312	648
Median (IQR)	10.0 (10.0, 10.0)	10.0 (9.0, 10.0)
Range	4.0–10.0	0.0–10.0
Likelihood to recommend provider			0.736
Number with data	312	648
Median (IQR)	10.0 (10.0, 10.0)	10.0 (10.0, 10.0)
Range	2.0–10.0	0.0–10.0

Pre-COVID: November 2019 to February 2020; During-COVID: March 2020 to April 2021; IQR: interquartile range.

After the exclusion of 27 study visits that occurred during the COVID pandemic timeframe, 621 movement disorder MD clinic encounters were further analyzed based on the modality of the encounter (in-person vs. TH). A significant difference in patient age and visit type (new vs. return) was observed between in-person and TH clinic visits during the pandemic: the mean age of in-person patients was 68, compared with 71 for TH (p-value = <0.001) (Table 2). Additionally, there were significantly higher return visits in the TH group compared to in-person (TH: 95%, in-person: 75%, p-value = <0.001). No differences in satisfaction parameters were observed when comparing in-person to TH encounters with respect to LTR location (p = 0.659), LTR provider (0.892), and “spent enough time” score (0.395).

Table 2.

Demographic and satisfaction comparison between in-person and telehealth visits during the COVID pandemic.

	In-Person (N = 365)	Telehealth/video (N = 256)	p value
Age (years)			<0.001
Number with data	365	256
Median (IQR)	68.0 (59.0, 73.0)	71.0 (62.0, 77.0)
Range	17.0–91.0	19.0–93.0
Gender			0.663
Number with data	365	256
Female	169 (46.3%)	114 (44.5%)
Male	196 (53.7%)	142 (55.5%)
COVID time
Number with data	365	256
Pre COVID	0 (0.0%)	0 (0.0%)
During COVID	365 (100.0%)	256 (100.0%)
New or return visit			<0.001
Number with data	365	256
Return visit	273 (74.8%)	244 (95.3%)
New visit	92 (25.2%)	12 (4.7%)
Likelihood to recommend location			0.659
Number with data	365	256
Median (IQR)	10.0 (10.0, 10.0)	10.0 (9.0, 10.0)
Range	0.0–10.0	1.0–10.0
Likelihood to recommend provider			0.892
Number with data	365	256
Median (IQR)	10.0 (10.0, 10.0)	10.0 (10.0, 10.0)
Range	0.0–10.0	2.0–10.0
Spent enough time			0.395
Number with data	143	163
Median (IQR)	10.0 (9.5, 10.0)	10.0 (10.0, 10.0)
Range	3.0–10.0	3.0–10.0

IQR: interquartile range.

Additional qualitative survey questions regarding patient satisfaction were answered by 58% (n = 360) of patients in the during-COVID timeframe, including 161 TH encounters and 199 in-person encounters. In the TH group, 75% or more of participants gave a score of 8–10 out of 10 for the satisfaction parameters of “understanding of care plan,” “care needs met,” “spent enough time,” and “easy to connect” (Figure 2). The survey question “prefer telehealth visit” received scores of 6–10 out of 10% by 50% of respondents (Figure 2).

Figure 2.

Patient satisfaction for aspects of in-person and telehealth visits.

Additional sub-analysis of the TH group in the during-COVID timeframe was performed to see if there were any differences in TH preferences between different age groups. There was no statistically significant difference in respondent's preference for a TH visit between age groups of greater than 60, younger than 30 or between 30 and 60, with average scores of 6, 6.5, and 5 out of 10, respectively (Table 3). The age groups of >60 and 30–60 gave a score of 10 out of 10 for ease to connect to a TH visit, while the <30 age group gave an average score of 6.5 (Table 3).

Table 3.

Patient satisfaction with telehealth by age group.

	Age > 60 (N = 133)	Age < 30 (N = 4)	Age 30–60 (N = 25)	p value
Prefer a Telehealth Visit				0.893
Number with data	130	4	24
Median (IQR)	6.00 (4.00, 8.00)	6.50 (3.75, 8.00)	5.00 (4.00, 8.25)
Range	0.00–10.00	0.00–8.00	0.00–10.00
Easy to Connect to telehealth				0.743
Number with data	132	4	25
Median (IQR)	10.00 (7.75, 10.00)	6.50 (2.75, 10.00)	10.00 (8.00, 10.00)
Range	0.00–10.00	2.00–10.00	2.00–10.00

IQR: interquartile range.

Discussion

The COVID-19 pandemic served as a powerful inciting factor for the rapid utilization of TH in the ambulatory neurology setting. This study confirmed the abrupt rise of TH utilization in an ambulatory movement disorders center during the peak of the COVID-19 pandemic, and its continued utilization, albeit at lower rates, following the pandemic's height. Increased rates of TH utilization in PD care are expected to stay, as TH can improve access to specialized care. Access to movement disorders specialists will worsen if innovations such as TH are not adopted, as the shortage of neurologists in the USA is expected to grow to 19% by 2025, and PD prevalence in the most populous nations is projected to double to 8.7–9.3 million by 2030.^18,19

Increased TH utilization in PD care is also driven by its demonstrated applicability to specialized aspects of PD care. TH improves delivery of care to nursing home residents with PD and remote rehabilitation services have proven to be effective.^20,21 Additionally, effective TH delivery of palliative care as well as remote Deep Brain Stimulation monitoring for individuals with PD has been demonstrated, improving access to these specialist-delivered services.^22,23

With increased rates of TH, it has become more vital to understand patient satisfaction with TH, and the widespread use of TH during the COVID-19 pandemic created the opportunity to study this on a larger scale. Assessing TH satisfaction across medical sub-specialties during the COVID-19 pandemic, an integrative review found high levels of patient and provider satisfaction with TH visits.²⁴ With respect to neurology specifically, a large survey-based study of 753 neurologic patients with TH visits between March and May of 2020 found that 77% of patients felt that their needs were met by TH visits.²⁵ Regarding the experience of neurology sub-specialties during the COVID-19 pandemic, high satisfaction has been reported in the neuromuscular population.²⁶ With respect to PD patient satisfaction with pandemic-era TH specifically, a survey of 74 individuals with PD demonstrated that almost all were very satisfied with televisits, with 61.6% comfortable with the technology, and the majority reported ease of access to a specialist, as well as cost, travel and time savings.²⁷

To our knowledge, our study is the largest observational survey-based study to date of ambulatory movement disorders patients’ TH satisfaction, examining survey responses of 960 patients, 648 of which occurred during the COVID-19 pandemic. Survey analysis yielded several key findings regarding TH satisfaction in movement disorders outpatient clinics.

This study confirmed that the overall degree of patient satisfaction for TH visits did not significantly differ from in-person encounters in an ambulatory movement disorders setting. Survey respondents’ scores of their likelihood to recommend providers and the clinic itself did not differ between TH or in-person visits, and did not differ between pre- and during-COVID timeframes. Regarding TH visits specifically, the majority of respondents were satisfied with their understanding of their care plan, felt that their care needs were met, and that the provider spent enough time during the visit. These factors are important, as they maintain a positive provider–patient relationship and build trust, which is vital to providing quality patient care. Regarding the patient experience with the technological aspect of TH, the majority of respondents were satisfied by the ease to connect to their TH visits. This supports an important counter-argument to the often cited “negative” aspect of TH, namely the challenge of navigating technology. Importantly, although respondents reported satisfaction with TH care and ease to utilize TH, only 50% of respondents gave a positive score when asked if they preferred a TH visit. A likely explanation for this is that patients do not wish for their in-person clinic visits to be supplanted by TH. Alternatively, patients might welcome a hybrid model where in-person and TH visits are alternated, or TH visits are employed selectively to overcome certain burdens of travel, such as weather-related, transportation-related, and care-partner availability related barriers. More nuanced surveys should be utilized to delve into the details of patient preference for integrating TH into their care model.

Further survey analysis addressed the question of whether there are age-related barriers to utilization of TH to address the presumption that older populations are not as familiar with, and adept at using technological devices and TH platforms. This question is particularly relevant in movement disorders practice, where the majority of conditions affect an aging population in which mobility and cognitive-related barriers arise. Survey results showed that individuals 60 and older were similarly satisfied with the ease to connect to TH visits, with an average score of 10 out of 10. Respondents’ answers to free-response questions included comments that TH connection was easy despite considering themselves to be technologically challenged, or that a care partner or family member had assisted in the process.

This survey-based study is limited by the likelihood of response bias, in that individuals willing to complete the post-encounter survey may have been influenced to do so by their satisfaction with the in-person or TH visit. Additionally, the single-center nature of the study limits the findings’ generalizability to other movement disorders centers.

Conclusion

Even before the COVID-19 pandemic, TH care models were established as efficient and sustainable in the movement disorders field, increasing access to specialized care and reducing travel, cost, and time burdens.^28–30 Therefore, utilization of TH for movement disorders and PD-specific care was touted by experts and promoted by the International Parkinson and Movement Disorder Society.^31,32 As a result of the widespread TH adoption during the COVID-19 pandemic, TH has become more integrated and available in ambulatory care settings, including movement disorders clinics. Results from this large single-center survey study add to the growing body of evidence that neurologic patients are satisfied by the care received during TH visits, and by their ability to utilize TH technology. Importantly, this patient satisfaction with TH is inclusive of movement disorders patients, though likely to be older and potentially more cognitively challenged. Therefore, as has been argued by eminent movement disorder specialists, TH should remain a part of movement disorders’ patient care, as it is an important tool to reduce patient and caregiver burden and increase accessibility to movement disorder specialists.^33,34

Footnotes

Contribution statement

All the authors contributed to the conception or design of the work, the acquisition, analysis, and interpretation of data, drafting the work, and revising it critically for important intellectual content. Each of the coauthors has seen and agrees with each of the changes made to this manuscript in the revision and how his or her name is listed

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Shubhendu Mishra

Danielle N Larson

References

Smith

Thomas

Snoswell

, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare 2020; 26: 309–313.

Bloem

Dorsey

Okun

. The coronavirus 511 disease 2019 crisis as catalyst for telemedicine for chronic 512 neurological disorders. JAMA Neurol 2020; 77: 927–928.

Grossman

Han

Balcer

, et al. Rapid implementation of virtual neurology in response to the COVID-19 pandemic. Neurology 2020; 94: 1077–1087.

Larson

Schneider

Simuni

. A new era: The growth of video-based visits for remote management of persons with Parkinson’s disease. J Parkinson’s Dis 2021; 11: S27–S34.

Schneider

, et al. Remote administration of the MDS-UPDRS in the time of COVID-19 and beyond. J Parkinson’s Dis 2020; 10: 1379–1382.

Huis In't Veld

van Dijk

Hermens

, et al. A systematic review of the methodology of telemedicine evaluation in patients with postural and movement disorders. J Telemed Telecare 2006; 12: 289–297.

Samii

Ryan-Dykes

Tsukuda

, et al. Telemedicine for delivery of health care in Parkinson’s disease. J Telemed Telecare 2006; 12: 16–18.

Dorsey

Deuel

Voss

, et al. Increasing access to specialty care: A pilot, randomized controlled trial of telemedicine for Parkinson's disease. Movement Disorder 2010; 25: 1652–1659.

Cubo

Gabriel-Galan

Martinez

, et al. Comparison of office-based versus home web-based clinical assessments for Parkinson’s disease. Movement Disorder 2012; 27: 308–311.

10.

Abdolahi

Scoglio

Killoran

, et al. Potential reliability and validity of a modified version of the unified Parkinson’s disease rating scale that could be administered remotely. Parkinsonism Relat Disord 2013; 19: 218–221.

11.

Dorsey

, et al. Randomized controlled clinical trial of “virtual house calls” for Parkinson’s disease. JAMA Neurol 2013; 70: 565–570.

12.

Beck

Beran

Biglan

, et al. National randomized controlled trial of virtual house calls for Parkinson disease. Neurology 2017; 89: 1152–1161.

13.

Wilkinson

Spindler

Wood

, et al. High patient satisfaction with telehealth in Parkinson disease: A randomized controlled study. Neurol: Clin Pract 2016; 6: 241–251.

14.

Hanson

Truesdell

Stebbins

, et al. Telemedicine vs office visits in a movement disorders clinic: Comparative satisfaction of physicians and patients. Mov Disord Clin Pract 2019; 6: 65–69.

15.

Dorsey

Wagner

Bull

, et al. Feasibility of virtual research visits in fox trial finder. J Parkinsons Dis 2015; 5: 505–515.

16.

Marzinzik

Wahl

Doletschek

, et al. Evaluation of a telemedical care programme for patients with Parkinson’s disease. J Telemed Telecare 2012; 18: 322–327.

17.

Andrews

Berghofer

Long

, et al. Satisfaction with the use of telehealth during COVID-19: An integrative review. Int J Nurs Stud Adv 2020; 2: 100008.

18.

Dorsey

Constantinescu

Thompson

. Projected number of people with Parkinson disease in the most populous nations, 2005 through 2030. Neurology 2007; 68: 384–386.

19.

Dall

Storm

Chakrabarti

, et al. Supply and demand analysis of the current and future US neurology workforce. Neurology 2013; 81: 470–478.

20.

Biglan

Voss

Deuel

, et al. Telemedicine for the care of nursing home residents with Parkinson’s disease. Mov Disord 2009; 24: 1073–1076. PMID: 19353687.

21.

Anghelescu

. Telerehabilitation: A practical remote alternative for coaching and monitoring physical kinetic therapy in patients with mild and moderate disability Parkinson’s disease during the COVID-19 pandemic. Parkinsons Dis 2022; 8: 4370712.

22.

Katz

. Telehealth increases access to palliative care for people with Parkinson’s disease and related disorders. Ann Palliat Med 2020; 9: S75–S79.

23.

Pintér

Járdaházi

Janszky

, et al. Potential clinical and economic benefits of remote deep brain stimulation programming. Sci Rep 2022; 12: 17420.

24.

Houston

Kennedy

O'Malley

, et al. Telemedicine in neurology: a scoping review of key outcomes in movement disorders. Telemed e-Health 2021; 28. DOI:10.1089/tmj.2021.0117.

25.

Olszewski

Thomson

Strauss

, et al. Patient experiences with ambulatory telehealth in neurology: Results of a mixed-methods study. Neurol: Clin Pract 2021; 11: 484–496.

26.

Hooshmand

Cho

Singh

, et al. Satisfaction of telehealth in patients with established neuromuscular disorders. Front Neurol 2021; 12: 667813. eCollection 2021. DOI:10.3389/fneur.2021.667813.

27.

Deeb

Hess

Gamez

, et al. Response to telemedicine visits from patients with Parkinsonism during the COVID-19 pandemic on postvisit surveys. Patient Exp 2021; 15. DOI: 10.1177/2374373521997224.

28.

Barbour

Arroyo

High

, et al. Telehealth for patients with Parkinson’s disease: Delivering efficient and sustainable long-term care. Hosp Pract 2016; 44: 92–97.

29.

Butcher

. SPECIAL DELIVERY telehealth’s tremendous promise in improving Parkinson’s disease care. Hosp Health Netw 2016; 90: 14.

30.

Ben-Pazi

Browne

Chan

, et al. The promise of telemedicine for movement disorders: An interdisciplinary approach. Curr Neurol Neurosci Rep 2018; 18: 1–10.

31.

Schneider

Biglan

. The promise of telemedicine for chronic neurologic disorders: The example of Parkinson’s disease. Lancet Neurol 2017; 16: 541–551.

32.

Achey

Aldred

Aljehani

, et al. The past, present and future of telemedicine for Parkinson’s disease. International Parkinson and movement disorder society telemedicine task force. Mov Disord 2014; 29: 871–883. Epub 2014 May 17.

33.

Dorsey

Bloem

Okun

. A new day: The role of telemedicine in reshaping care for persons with movement disorders. Mov Disord 2020; 35: 1897–1902.

34.

Dorsey

Okun

Bloem

. Care, convenience, comfort, confidentiality and contagion: The 5 c’s that will shape the future of telemedicine. J Parkinson’s Dis 2020; 10: 893–897.